Caring must be prioritized over coding

Physicians Practice February 1, 2023
Jay Anders, MD

Is the coding taking priority over the caring?

Unlike traditional Medicare fee-for-service plans, Medicare Advantage (MA) programs receive a capitated monthly payment for an individual beneficiary’s cost of care that is partially based on a risk score, which increases or decreases depending on an enrollee’s health compared to a national average.

Health plans offer greater financial incentives to providers for more thorough documentation and coding of beneficiaries’ diagnoses. In other words, higher risk scores translate to higher payments. Naturally this leads to instances of payers gaming the system with so-called “upcoding” or “uncorrected coding intensity.”

The practice has become so widespread that CMS currently applies a 5.9% reduction to MA risk scores to counter the effect. Now, the Medicare Payment...

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